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The effects of synchronized distance education on anxiety, depression, and academic achievement in first year doctor of pharmacy students in an accelerated curriculum

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Currents in Pharmacy Teaching and Learning 4 (2012) 285–291
http://www.pharmacyteaching.com

Research letter

The effects of synchronized distance education on anxiety,
depression, and academic achievement in first year doctor of
pharmacy students in an accelerated curriculum
Scott Massey, PhD, PA-Ca, Louise Lee, MHA, PA-Cb, Susan White, MDc,
Carroll-Ann W. Goldsmith, DScd,*
a

Department of Physician Assistant Studies, Misericordia University, Dallas, PA
Physician Assistant Program, Tufts University School of Medicine, Boston, MA
c
School of Physician Assistant Studies, Manchester/Worcester, Massachusetts College of Pharmacy and Health Sciences, Manchester, NH
d
Department of Pharmaceutical Sciences, School of Pharmacy, Worcester/Manchester, Massachusetts College of Pharmacy and Health
Sciences, Manchester, NH
b

Abstract
Objectives: To compare depression, anxiety, and academic achievement in a pilot study of two cohorts of first year doctor of
pharmacy students in an accelerated curriculum, one receiving the majority of class content via synchronized distance
education, the other via traditional delivery (TD).
Methods: Depression and anxiety were measured using Beck Depression Inventory-II and Brief Symptom Inventory-18
surveys at the beginning and end of students’ fall and spring trimesters and at the end of the summer trimester. Academic
achievement was measured by final course averages across the curriculum.
Results: Depression, anxiety, and academic achievement were not significantly different between synchronized distance
education and TD cohorts. Depression scores for all students significantly increased during each trimester and over the
academic year.
Conclusions: No significant differences in depression, anxiety, or academic success were found between synchronized
distance education and TD students. All students experienced significant increases in depression over time, regardless of mode
of instruction.
© 2012 Published by Elsevier Inc.
Keywords: Depres; sion; Anxiety; Academic achievement; Pharmacy curriculum; Synchronized distance education

Introduction
Communications technology and infrastructure development now allow effective delivery of interactive educational
content in real-time across broad geographic terrain. The
use of synchronous distance education (SDE) and virtual

* Correspondence to: Carroll-Ann W. Goldsmith, DSc, Massachusetts College of Pharmacy and Health Sciences, Department of
Pharmaceutical Sciences, School of Pharmacy Worcester/Manchester, 1260 Elm Street, Manchester, NH 03101.
E-mail address: carrollann.goldsmith@mcphs.edu
1877-1297/12/$ – see front matter © 2012 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.cptl.2012.05.005

classrooms is effective for delivering educational content1– 4; however, the impact of these technological innovations on levels of student depression and anxiety remains
largely unexplored.
Students actively engaged in professional educational
programs, such as medical school, often encounter considerable intellectual challenges at a time when they are subjected to incursions of significant financial debt and alterations of personal and family lives. Several studies have
shown elevated measures of depression, stress, and anxiety
in graduate, law, nursing, dental, and medical students.5–10
These data were confirmed at our own institution in physician assistant students, who showed increasing depression

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S. Massey et al. / Currents in Pharmacy Teaching and Learning 4 (2012) 285–291

and anxiety scores over the course of their first academic
year.11
The intensive doctor of pharmacy (PharmD) professional program exposes students to stressors similar to those
seen among students enrolled in other professional programs, though few studies exist assessing depression and
anxiety in pharmacy students enrolled in conventional programs.12–14 Moreover, no studies of anxiety or depression
symptoms were found for PharmD students enrolled in an
accelerated curriculum and who receive most of their didactic content education via SDE. This pilot study was
conducted to determine if anxiety, depression, and academic
achievement differed in two cohorts of first year PharmD
students in an accelerated curriculum who were separated
geographically and technologically. One of the cohorts received most of their first year pharmacy didactic course
work using real-time SDE, the other via onsite, traditional
delivery (TD).
It was hypothesized that measures of depression and
anxiety, using the established Brief Symptom Inventory-18
(BSI-18) and Beck Depression Inventory-II (BDI-II) selfreporting instruments, would be significantly different for
PharmD students in the SDE cohort compared with those in
the TD cohort and that SDE students would see greater
increases in depression and anxiety over time compared
with TD students. Based on previous studies indicating
distance education does not affect student academic
achievement,1– 4 it was further hypothesized that academic
achievement would not be statistically different between the
cohorts in this study.

Methods
Objectives
The objectives of this study were to measure and compare academic achievement and levels of anxiety and depression in a pilot study of two cohorts of PharmD students
enrolled in an accelerated (2-year, 10-month) curriculum.
One cohort received most of their course work on site, via
TD, while the other received most of their course work via
SDE. Two surveys were used to measure stress, anxiety, and
depression in the PharmD students enrolled in this study, the
BDI-II and the BSI-18.
Participants
Participants came from two different student cohorts in
the PharmD program at two of the three campuses at our
institution. The pool of participants included 53 incoming
students of the class of 2011 at the SDE campus and 163
students at the TD campus. Both groups entered the didactic
portion of the PharmD program at this time. Over the course
of the academic year student enrollment in first year courses
fluctuated, as some students withdrew from their coursework and some students re-entered the program after having
taken a leave of absence. All students who returned to the

program were considered in the analysis of course grades,
but only students who had agreed to participate in the study
of depression and anxiety at the beginning of this work were
considered in the analysis of that portion of this study.
The curriculum and learning experience were equivalent
between the two cohorts; the only difference in pedagogy
was the SDE format, a technology that allowed for interactive classroom experiences. The experimental group, the
entering class at the SDE campus, received most classroom
content via SDE, transmitted in real-time from the control
group’s location, the TD campus. The TD control cohort
received the same classroom content, most of which transpired with faculty physically present.
Before conducting this work and enrolling participants, a
power analysis was performed to determine the number of
participants necessary to produce valid statistics for this
study. For the power analysis for the BDI-II survey, it was
assumed that the PharmD students enrolled in this study
would provide results similar to those found in a study of
medical students, in which mean BDI scores ranged from
3.03 ⫾ 3.94 to 8.27 ⫾ 8.55 over the course of the 4-year
study.10 If students in this study showed a similar trend, for
a desired power of 0.80, statistical significance (p ⬍ 0.05)
could be seen with as few as 19 subjects in each cohort (TD
and SDE).
A power analysis was also conducted for the BSI-18
survey, which measures psychopathology and psychological distress.15–16 Results provided by Cochran and Hale,
who examined cohorts of male and female college students
and compared their levels of distress with that of adolescents and adults, were used as a close parallel student
population for comparison and to provide reasonable survey
scores to use in the power analysis.15 Although there are
multiple symptom scales produced by the BSI-18, focusing
on two of them illustrates that the number of participants
enrolled in this study was a large enough sample size to see
statistical significance. The Global Severity Index (GSI), an
overall measure of stress, was 0.71 ⫾ 0.42 for college
women in the Cochran study, and for adult women it was
0.36 ⫾ 0.35.15 An anxiety subscale can be generated from
the BSI-18; in the same study, BSI-18 anxiety scores were
0.81 ⫾ 0.54 for college women and 0.37 ⫾ 0.43 for adult
women.15 Again, assuming our participants would generate
similar results, 19 subjects in each cohort would be necessary for the desired power of 0.80 in this study.
Twenty-six students from the SDE cohort and 37 from
the TD cohort consented to participate in the study of
depression, stress, and anxiety in September 2008. The
protocol for this study was approved by the institutional
review board (IRB) and conducted according to institutional
review board guidelines. Students were given the option not
to participate in the study, and both cohorts of students were
informed that they could withdraw from participation at any
time and return at any time, if desired. Some students were
lost to attrition because of their opting out of participation.

S. Massey et al. / Currents in Pharmacy Teaching and Learning 4 (2012) 285–291

Thus, numbers of participants at the time of the survey are
noted within the figures.
Academic achievement was measured by comparing final course averages of all students in the SDE and TD
cohorts. While not all students agreed to participate in the
study of stress, anxiety, and depression by taking the BDI-II
and BSI-18 surveys, final course means were available for
all courses and used in this analysis. As participants were
self-selected to enter into the BDI-II and BSI-18 portion of
the study and were anonymously enrolled, we could not
track individual grades with individual participants, opting
instead to evaluate the effects of SDE and TD on all first
year PharmD students enrolled in our accelerated program.
Fifty-three and 163 students were enrolled as first year
students in the SDE and TD programs, respectively, at the
start of the academic year, but not all students completed all
courses during the year and some students who had taken
leaves of absence re-enrolled at different times during the
year. Because of this attrition and re-enrollment, the final
numbers of students within each didactic course varied, but
were at least 53 in the SDE cohort and 160 in the TD cohort
for all courses.

Methods
Both the BSI-18 and BDI-II were from Pearson Education,
Inc. (http://www.pearsonpsychcorp.com.au/productdetails/
225 and http://www.pearsonpsychcorp.com.au/productdetails/
39, respectively). The BSI-18 is an 18-question survey that
measures anxiety and depression using a five-point scale,
ranging from 0 to 4, for each of 18 questions. Results can be
reported as the total score produced by all 18 questions on
the survey, referred to as the GSI and an overall measure of
stress, or can be reported as three subscales of six questions
each, anxiety, depression, and somatization.17 Subscales on
the BSI-18 can be converted to standardized area T-scores,
characterized by a mean of 50 and standard deviation of 10.
Using community norms, as reported by the manufacturer,
for females and males combined, the mean T-score of 50
equates to a raw GSI score of 5, with a raw GSI score of 15
being within one standard deviation, and a score of 33 being
within two standard deviations.17 According to the BSI-18
manual, the average community GSI is 8 for women and 5
for men.17 Mean scores vary from one population to another. For example, as reported by Cochran and Hale, the
median GSI for college men and women was significantly
different from that of adult women and men.15 The instrument was used according to manufacturer instructions.17
The BDI-II is a 21-question survey that measures depression, and is often reported as a mean score.18 The BDI-II
measures depression using a four-point scale, ranging from 0
to 3, for each of 21 questions.19,20 BDI-II scores may be
presented as means, medians, or categorized according to severity of depression (total score of 0 –13 is considered minimal,
14 –19 mild, 20 –28 moderate, and 29 – 63 severe). It has been
reported that medical students’ BDI scores increased over the

287

course of their didactic period of study.10 The instrument was
used according to manufacturer instructions.18
Hypotheses and statistical analyses
The first research hypothesis was that there would be a
statistically significant difference in levels of anxiety and
depression between the students educated in the SDE cohort
and those in the TD cohort at each survey administration
after the first, baseline, administration. Nondirectional independent samples t tests were conducted to test for mean
differences between the SDE and TD cohorts at each survey
administration.
The second research hypothesis was that mean anxiety
and depression scores in each cohort would increase significantly over the three trimesters that encompassed the didactic year. Directional dependent samples t tests were
conducted to test for increases in stress and depression from
the beginning to the end of each of trimesters one and two.
A third test was conducted to test for increases from baseline to the fifth, summer, administration.
The final research hypothesis was that differences in
academic achievement between the SDE and TD cohorts
would not be statistically significant, based upon reports of
no difference in academic achievement using distance education technology.1– 4 Final course averages were used to
measure student achievement and compare the performance
of the SDE and TD cohorts. At the end of the fall (December 2008), spring (April 2009), and summer (July 2009)
terms, course means were recorded and overall course
means were compared across delivery models. Nondirectional independent samples t tests were conducted to test for
differences in academic achievement between the cohorts.
Study data were generated from September 2008 to July
2009, with levels of student anxiety and depression measured
five times (at baseline, September 2008; at the end of trimester
one, December 2008; at the beginning and end of trimester
two, January and April 2009, respectively; and at the end of
year one, July 2009) using the BSI-18 and BDI-II surveys.
No variables were manipulated during the study, nor did
one cohort receive benefits that the other did not receive. No
specific interventions were involved in the study. Participants had full access to counseling services at all times and
any student who was identified as being depressed, anxious,
or in need of academic support was promptly referred. This
study maintained strict adherence to the institution’s protocols for studies involving human subjects.

Results
Comparison of anxiety and depression scores in SDE and
TD students
It was hypothesized that the method by which students
received their didactic content would affect levels of anxiety
and depression; that is, that there would be significant differences in anxiety and depression scores between the stu-

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S. Massey et al. / Currents in Pharmacy Teaching and Learning 4 (2012) 285–291

18
16
14
12
10
8
6
4
2
0
Beginning Tri 1
n=25, SDE
n=26, TD

End Tri 1
n=24, SDE
n=21, TD

Beginning Tri 2
n=12, SDE
n=10, TD

SDE, BDI
SDE, GSI

End Tri 2
n=15, SDE
n=12, TD

End Tri 3
n=7, SDE
n=12, TD

TD, BDI
TD, GSI

Fig. 1. Comparison of BDI and GSI scores over time in TD and
SDE cohorts.

dents who received their content via SDE and those who
received theirs via TD. This was not the case: the SDE and
TD groups’ BDI-II and GSI mean scores were not statistically different at each of the five administrations, indicating
that anxiety and depression were the same regardless of
delivery model (Fig. 1). At two points during the study,
mean BDI-II scores increased from the category of minimal
depression to the category of mild depression18 in a specific
student cohort. This first occurred at the end of the second
trimester in the SDE student participants, though their mean
BDI-II score was not statistically different from the TD
students’ mean score at the same point. Similarly, mean
BDI-II scores among the TD student participants increased
to the category of mild depression18 at the end of the third
trimester, though this mean score was not statistically different from the SDE students’ mean score at the same time.
Mean scores on the BSI-18 somatization subscale (BSI_
SOM), BSI-18 depression subscale (BSI_DEP), and BSI-18
anxiety subscale (BSI_ANX) did not differ significantly
between the TD and SDE cohorts (Fig. 2).

Fig. 3. Comparison of mean depression ⫾ SD scores from the
beginning to the end of trimester one (September to December). *
p ⫽ 0.000; ** p ⫽ 0.023; n ⱖ 34.

Depression scores over time in all students
Statistically significant increases were seen in BDI-II
mean scores in all students from the beginning to the end of
each trimester and from baseline to the end of the first
didactic year (Figs. 3–5). Scores on the depression subscale
of the BSI-18 (BSI_DEP) were also significantly increased,
or nearly significantly increased, in all students from the
beginning to the end of each trimester and from baseline to
the end of the first didactic year (Figs. 3–5). After winter
break (the end of trimester one to the beginning of trimester
two), student BDI scores in both cohorts returned to, or fell
below, the initial baseline scores, but never again returned
to baseline at any other point in the study (Fig. 1).

7
6
5
4
3
2
1
0
Beginning Tri 1
n=25, SDE
n=26, TD

End Tri 1
n=24, SDE
n=21, TD

Beginning Tri 2
n=12, SDE
n=10, TD

SDE, SOM
SDE, DEP
SDE, ANX

End Tri 2
n=15, SDE
n=12, TD

End Tri 3
n=7, SDE
n=12, TD

TD, SOM
TD, DEP
TD, ANX

Fig. 2. Comparison of BSI subscores over time in TD and SDE
cohorts.

Fig. 4. Comparison of mean depression scores ⫾ SD from the
beginning to the end of trimester two (January to April). * p ⫽
0.006; ** p ⫽ 0.065; n ⫽ 18.

S. Massey et al. / Currents in Pharmacy Teaching and Learning 4 (2012) 285–291

289

6.7%) than the SDE (91.8 ⫾ 4.6%) cohort. The lab portion
of this course was the only course in the curriculum that was
taught on site in both locations by different instructors.

Discussion

Fig. 5. Comparison of mean depression scores ⫾ SD from the
beginning (baseline) to the end (July) of didactic year one; baseline
to July. * p ⫽ 0.001; ** p ⫽ 0.055; n ⫽ 17.

Global stress, somatization, and anxiety scores over time
in all students
Although mean depression scores increased for all student participants over time, mean scores on the GSI, BSI-18
somatization subscale (BSI_SOM), and BSI-18 anxiety subscale (BSI_ANX) did not significantly increase over any trimester or from baseline to the end of the year. Two comparisons were nearly significant: a comparison between the mean
baseline GSI score to the mean final GSI score of the year had
a p value of 0.076 and a comparison between the mean GSI
score at the beginning of the second trimester to the mean
GSI score at the end of that trimester had a p value of 0.101.
After winter break (the end of trimester one to the beginning
of trimester two), student GSI scores and subscores in both
cohorts returned to, or fell below, the initial baseline scores,
but never again returned to baseline at any other point in the
study (Figs. 1 and 2).
Comparison of academic achievement in SDE and
TD students
Academic achievement was not significantly different
between the SDE and TD cohorts (Table 1). The overall
mean for all courses for the SDE cohort was 85.05 ⫾
3.40%, while that of the TD cohort was 83.38 ⫾ 2.71%. A
course-by-course comparison yielded only one course for
which course means differed between the SDE and TD
groups, Introduction to Pharmacy Care 3, a course that had
both lecture and lab components. The lecture component
was taught via SDE, with both SDE and TD students participating in the class at the same time. The mean lecture
scores for this course were not significantly different between the SDE (88.8 ⫾ 3.5%; n ⫽ 53) and TD (88.1 ⫾
5.5%; n ⫽ 160) groups. The overall course averages for
Introduction to Pharmacy Care 3 differed because the lab
averages differed significantly between the cohorts, with the
TD cohort having a significantly lower lab average (85.8 ⫾

These results indicate that mode of delivery did not
significantly affect measures of stress, anxiety, and depression in a subset of first-year PharmD students enrolled in an
accelerated curriculum at each of five administrations over
the course of the students’ first didactic year (Figs. 1 and 2).
Instead, as seen with students enrolled in other professional
programs,5–10 mean depression scores of all PharmD student participants in this study, regardless of mode of delivery, increased as they progressed through the didactic year
and each trimester (Figs. 3–5). As the program in which the
students are enrolled is accelerated, it is possible that the
upward trend in scores is a reflection of the accelerated
program, though similar research in more traditional, nonaccelerated, programs showed similar increases in depression and anxiety over time. For example, our results are
similar to those reported by Clark and Zeldow, who found
that medical students at the onset of their first year of
medical school had a mean BDI score of 3.28 ⫾ 4.41; this
score had increased to 6.14 ⫾ 6.22 by the spring of their
first year of medical school.10 Over the course of the 4-year
study mean scores ranged from 3.03 ⫾ 3.94 to 8.27 ⫾
8.55.10
As a more general comparison, studies on undergraduate
college student populations have not shown significantly
higher self-reported levels of depression and anxiety when
compared with the general population accepted norms.21,22
However because of the use of different instrumentation in
these studies, it is difficult to draw general conclusions from
them to be able to compare them to this study’s population of
participants. A few studies implicate a lack of development of
coping skills as a predictor of perceived depression and anxiety
among general college students, especially early on during the
freshman year,23 rather than academic stress. This study’s
participants were graduate students, not freshman; therefore
lack of development of coping skills is less likely to explain the
increases in perceived depression reported here.
Whether the magnitude of change in the mean depression scores in our students is clinically relevant is not clear.
It is notable that there is no universally accepted clinically
significant difference for BDI-II scores, though previous
data indicate that a five-point change may indicate a minimally important clinical difference.24 In our participants,
the mean change in BDI-II scores over time did change by
five points or more (Figs. 1, and 3-5). As this change over
time may be clinically relevant, it is important to consider
interventions by faculty, staff, administrators, and the students themselves to help alleviate depression.
At the beginning of trimester two, after winter break,
student BDI and GSI scores in both cohorts returned to, or
fell below, the initial baseline scores. This is encouraging,

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S. Massey et al. / Currents in Pharmacy Teaching and Learning 4 (2012) 285–291

Table 1
Comparison of course averages for didactic year 1
Course

Location

Average (%)

SD (%)

n

Physiology/pathophysiology I

SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD
SDE
TD

84.1
82.3
84.3
82.5
84.9
84.1
82.4
82.1
84.9
83.4
84.6
83.8
86.2
84.2
85.5
84.9
82.8
81.4
79.5
77.8
79.8
79.1
85.8
84.2
90.3
87.0†
88.8
88.1
91.8
85.8†

6.1
6.8
7.7
8.0
5.4
5.8
6.9
6.7
5.0
6.1
6.5
7.0
6.5
6.7
4.8
6.5
7.5
8.2
7.9
7.1
7.8
8.8
5.5
6.3
3.3
6.7
3.5
5.5
4.6
6.7

54
164
54
164
54
164
54
164
54
164
55
162
54
162
53
163
53
163
55
163
56
165
53
160
53
160
53
160
53
160

Biochemistry I
Pharmaceutics
US Health Care and Public Health
Pharmacy Law
Biochemistry II/nutrition
Pharmacokinetics
Drug literature
Immunology
Physiology/pathophysiology II
Pharmacology, toxicology, medicinal chemistry I
Self-care therapeutics
Introduction to pharmacy care 3 overall*
Introduction to pharmacy care 3 lecture
Introduction to pharmacy care 3 lab

* The overall average for this course is derived from the lecture and lab components.
† Significantly different from SDE, p ⬍ 0.001.

as the program in which the students were enrolled is
accelerated; therefore, consideration must be given to the
long-term effects of the accelerated pace on student health.
Although we did not make an assessment at the beginning
of trimester three, and cannot know that the same trend
would have continued, we consider the return to baseline
after a short break to be positive. One interpretation of these
results is that students were provided sufficient time between trimesters to return to their more typical, healthy
scores on these assessments.
Mean differences in academic achievement, measured
using final course grades from the first PharmD didactic
year, were not statistically different between the two groups,
SDE and TD, with one exception, the laboratory component
of the one course for which SDE was not a factor. The lab
portion of this course was taught on site in both locations
and the difference in averages is likely attributable to differences in instructors and/or interpretation of the grading
rubrics by these instructors. Thus, despite the SDE cohort
having most of their didactic lessons taught by off-site
faculty, this group was able to achieve grades that did not

differ significantly from their TD classmates. This finding
adds to the previous work1– 4 to help assure students, faculty, and administrators that SDE is an effective model for
didactic education in an accelerated PharmD program.
We have conducted similar work in physician assistant
(PA) studies students at our institution. The PA curriculum also
uses SDE, but the PA students have the opposite configuration
of the PharmD students described in this study with regard to
the campus at which the SDE and TD courses are taught. The
results with PA students paralleled those found in this study
with PharmD students: the PA students in the SDE cohort were
as academically successful as their peers, and over time both
cohorts exhibited significant increases in depression and anxiety.4,11 The temporal increase in depression and anxiety seen
in both PA and PharmD students in these studies strengthens
the work previously conducted in students in other health care
professional programs and should be considered when developing best practices.5–10
It should be noted that the PharmD results reported
herein represent a subset of students in one class progressing through an accelerated program and that small subject

S. Massey et al. / Currents in Pharmacy Teaching and Learning 4 (2012) 285–291

numbers and dropouts over time may have contributed to
lack of significance in some of the parameters studied,
including the GSI score and the somatization and anxiety
subscores of the BSI-18 survey, many of which increased in
all students over time, but not significantly (Fig. 2). This
may be of some practical significance, especially considering the relatively low number of participants.
Although the number of participants enrolled at the start of
the study was greater than needed for appropriate statistical
power, as noted above, students were allowed to opt out of the
study at any point. The numbers of participants declined over
course of the study, but despite the decreased numbers of
participants, statistically significant changes were evident in
those who remained in the study. To increase subject numbers
and more precisely reflect the influence of mode of didactic
delivery on depression and anxiety, this pilot study ought to be
expanded to include other classes of PharmD students at the
institution’s SDE and TD campuses. It is believed that larger
subject numbers and the ability to follow more cohorts longitudinally will provide further statistical validity to the data and
valuable insights to plan interventions that can be implemented
to define emerging best practices for student services, academic support services, and pedagogy for students in programs
that use SDE to deliver classroom content.
Conclusions
In this pilot study the method of classroom content delivery, traditional or synchronized distance education, did not
significantly affect first year PharmD students’ levels of depression and anxiety or their academic achievement in an
accelerated curriculum. Nonetheless, all PharmD students experienced increased levels of depression over the course of
their first year in the accelerated curriculum, an outcome that
should be considered when developing best practices for administrators, staff, faculty, and students enrolled in PharmD
programs. Further study, with larger numbers of students who
remain enrolled for the duration of the study, are followed
longitudinally, and who are enrolled in different years of the
curriculum, is needed to validate these results.
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